HomeMy WebLinkAboutGadomski OFFI-CE OF THE TOWN CLERK • c3IFO -
` Town of Southold - - � ,- �Ce
Judith T. Terry, Town Clerk • Z "
Town Hall,. 53095 Main Road
P. O. Box- 1179 n .;y " :�c,, -
Southold, New York 11971 Q ® " �- •
TelephoneO s
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(516) 765-1801
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TOWN OF SOUTHOLD
• SOUTHOLD WASTEWATER DISPOSAL DISTRICT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 520 Residential X
Non-Residential •
- Fee $ 10.00
Septic Cesspool X
NAME OF OWNER: Charlotte Gadomski f.
OWNER MAILING ADDRESS: Summer Lane
Southold, New York 11971
_ OWNER PROPERTY ADDRESS: Summer Lane
Southold, New York -
OWNER TELEPHONE NUMBER: 516-765-2432
TAX MAP NO. : Section 78 Block g Lot - 13
CROSS STREET: North Bayview Road
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X New Existing X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: Approximately 1980
Judith T. 6ferry
Southold Town Clerk
DATE: December 4, 1987
(TOWN SEAL)
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OFFICE OF THE TOWN CLERK 0cl\VFair '
Town of Southold Application No.v`-a2v
Judith T. Terry, Town Clerk
�
Town Hall, 53095 Main Road I Residential
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P. O. Box 1179 �, 'b = , ' z Non-Residential
Southold, New York 11971
Telephone
(516) . 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
6-10
Fee $ ! D
DATE / /. cgd-, '`7'
OWNER NAME: C 14APLGA/DOIr)'15(l
OWNER MAILING ADDRESS: S0yr1mG 12.
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 765--
X430._
TAX MAP NO. : Section g Block 9 Lot
CROSS STREET: !/-}cp • -Bay v
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool A New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: t0 9gQP(v -ox.
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.)
C V i). I E CA
Si natuQe of Applicant
RECEIVED BY:" Cie ,„
RECEIVE ark's O Tice
DATE.
RECEIVED
• �
� Southold
DEC 04 '997
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Tnwn Clerk Southold
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